Death Preoccupations and Suicidal Behavior in Children

Cynthia R. Pfeffer

A child’s obsessions with death are compelling and disturbing concerns for those who know the child well. Such a situation becomes transformed into a devastating event when the child has successfully taken his own life. This tragedy leaves the survivors in a state of profound shock, remorse, disbelief, and guilt. Such occur- rences must be prevented.

Unfortunately, children’s warning signs of potentially suicidal actions are often not sufficiently heeded, recognized, or acknowledged by those who are intimately involved with the child. A lack of early response to such distress in children is based upon many facts, misconceptions, and social restraint. Furthermore, to date, the childhood suicidal phenomenon is relatively poorly understood by clinicians and even less well studied. The dearth of comprehensive knowledge about suicidal children, who are between 6 and 12 years old, is fostered by several existing dilemmas.

First, the incidence of suicidal behavior among latency-age children has not been completely established. Contributing reasons for this are beliefs that suicidal be- havior does not exist in young children because young children cannot compre- hend that their actions may result in an irreversible fatal outcome. In addition, it is thought that children are not physically or intellectually mature enough to be able to plan and carry out life threatening actions. Other reasons are that the United States Office of National Vital Statistics does not catalogue suicide as a cause of death in children less than 10 years of age. Furthermore, there are rela- tively few reports that attempt to determine the incidence of children with sui- cidal threats and attempts.

Second, even if statistics were more readily available, they would probably re- flect gross under-estimates of incidence. Social restraints due to family secretiveness about cause of death, community political pressures that may influence document- ing the real cause of death, and spiritual and philosophical belief systems that create taboos in acknowledging a suicidal death, contribute to the motivation for not accurately reporting a death as suicide.

Third, the determination of cause of death is frequently difficult and not pre- cise. One study points out the discrepancies that often arise in diagnosis. Mclntire and Angle (1) evaluated 60 consecutive patients ages 6 to 18 years who were treated in two poison control centers and found that the hospital reports docu-

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mented accidents in 42 percent of the cases and suicidal behavior in 58 percent. However, the researchers concluded that 4 percent of the cases were accidents, 70 percent were suicidal gestures, 2 percent were suicide attempts, 22 percent involved intoxications, and 2 percent were homicides. In like manner, it is a fact that accidents are the leading cause of death in children but it is not clear how accurate or comprehensive the evaluations in determining the cause of death have been for deaths of chddren that are reported as accidents. Perhaps many of the reported accidental deaths may be suspected suicides.

Fourth, the degree of anxiety generated by clinical work with such children often has precluded widespread research. Self-directed death preoccupations in children create such an impact on a therapist’s own psychic equilibrium that these self-directed actions generate intense thoughts about one’s own life and death fears and wishes, one’s philosophical principles about encouraging or discouraging another person’s death urges, and one’s ambivalent feelings of love and hate. As a result, many clinicians are overtly anxious in working with a potentially suicidal child. Such issues are vividly exemplified in the statements of one child psycho- analyst who said “a child’s vehement expression ‘if I’ll die they’ll start loving me’ makes me shudder, and I feel safe only after this phase has subsided; (2, p. 838).

Fifth, among the clinical investigations of suicidal latency-age children, many reports have been anecdotal and based on only a few examples (3, 4). There have been only a few systematic studies (5-11). However, among studies of suicidal behavior of children, not only have the methodologies vmied but many of the studies were retrospective (9, 12), lacked comparison groups (6, 9), or used only a small number of children (6). Noteworthy, is that additional systematic investiga- tions are critically needed.

Sixth, many issues relating to the characteristics and dynamics of suicidal be- havior of children have been neglected. Among the understudied issues are the developmental and phenomenological features of death thoughts, fantasies, fears, and wishes of suicidal children. Clarification of these issues may promote progress in early recognition or prevention of suicidal behavior of children, therapeutic interaction and treatment of suicidal children, and research of the predominant factors contributing to childhood suicidal behavior.

These considerations highlight the problems that currently hamper more accu- rate understanding of the suicidology of children. In this chapter, I wrll utilize a psychoanalytic and developmental approach to explain features of childhood suicidal behavior. I will endeavor to provide an overview of many aspects of current knowledge of suicidal latency-age children, who are 6 to 12 years old. Utilizing this overview, I will attempt to integrate knowledge about death concepts and pre- occupations of suicidal children. The chapter will conclude with several statements about important principles of intervention with suicidal children.

INCIDENCE OF CHILDHOOD SUICIDAL BEHAVIOR Completed suicide in children under 12 years old is considered rare (13-15).

However there has been concern about the apparent increase of suicides among the younger age groups. For example, among children 10 to 14 years old, the total number of suicidal deaths in 1975 was 170. The rate has tripled from 1955 to 1975. In 1955, the suicide rate for children I0 to 14 years old was 0.4 per one hundred thousand population annually but in 1975 the rate was 1.2 per one hundred

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DEATH PREOCCUPATIONS AND SUICIDAL BEHAVIOR IN CHILDREN 263

thousand population annually. In contrast, the number of suicides for 15 to 19- year-olds in 1975 was 1594 and this reflected a 15 times rate of suicide for the 15 to 19-year-old group than the 10 to 14-year-olds.

In an attempt to be more specific about clarifying the trends for completed suicide in young children, Shaffer (15) studied all the recorded suicides among children ages 14 or under in England and Wales between 1962 and 1968. There were 3 1 such deaths. Data was accumulated from coroners’ records, school reports, medical, psychiatric, and social service records. The results of the study indicated that none of the children was under 12 years and the rate of boys to girls was 2.3 to 1 . The most common methods used were carbon monoxide gas (43 percent), hanging (17 percent), drug overdose (13 percent), and firearms (10 percent). Fur- thermore, there was marked sex difference in relation to suicidal methods. More girls took an overdose of drugs and only boys hanged themselves. This findmg is similar to that reported by Hollinger (14) in which suicides by firearms, hanging, and poisoning with gas has been carried out predominantly by males. Shaffer (1 5) noted that the circumstances which seem to have led to the suicidal act were most commonly disciplinary crises between the child and parents or teachers. Of special concern was that 46 percent of the children had threatened or attempted suicide previously .

The incidence of children who threaten or attempt suicide has not been deter- mined with great validity. This is because existing reports have focused on only small population sizes or unique settings which may have excluded categories of children. It has been more recently recognized that suicidal threats and attempts in children are not uncommon (8, 10, 11, 15, 16). However, among the early reports that focused on observations of suicidal behavior of children, Bender and Schilder (6) recognized the clinical evidence of suicidal behavior among 18 children under 13 years of age out of a total of 2000 admissions of children and adolescents to the children’s service of Bellevue Psychiatric Hospital. They noted that suicidal behavior in children under 13 years old was much more common among boys. Ackerly (5) reviewing published reports stated that it seemed that between 1 and 5 percent of children brought to child psychiatry facilities present with suicidal hstories. However, Lukianowicz (16) noted that approximately 8 percent of children referred to two child guidance clinics in Northern Ireland either attempted or completed suicide.

Recent surveys indicate that incidence of childhood suicidal threats and at- tempts are higher than previously reported. In a sample of 58 latency-age children admitted to a large municipal hospital’s child psychiatric ward, 72 percent had suicidal ideas, threats, or attempts (10). Furthermore, among 100 children referred to this hospital unit, 33 percent showed suicidal behavior (17). Among a sample of children seen in the outpatient clinic of the same municipal hospital, 33 percent had suicidal ideas, threats, or attempts (1 1). This increased incidence may be due to an actual increase in suicidal ideas, threats, and attempts among children that is similar to the increased rate of completed suicides. Another explanation for this may be attributed to more thorough clinical observation and psychiatric assessment of children coming for psychiatric evaluations.

The methods of suicidal threats and attempts of children vary widely. Children utilize jumping, ingestion, hanging, burning, running into traffic, and stabbing (9- 11). There have been no reports in the literature of children shooting themselves. Jumping from heights seems to be the most common method of latency-age boys

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and girls (6 , 10, 11). Unlike older age groups, there does not seem to be a sex difference in the type of method used (10, 11).

DYNAMIC AND INTRAF’SYCHIC COMPONENTS OF CHILDHOOD SUICIDAL BEHAVIOR

Psychoanalytic theory proposes that motivation for behavior is based upon an individual’s wishes, fantasies, fears and prohibitions. Most of this doctrine stems from work with adults. However, in children, although fantasy is a very strong motivating factor for behavior, the assessment of fantasy of children must be con- sidered within a holistic context of the child’s level of developmental competence in cognitive, motor, and ego functioning spheres. Therefore, a child’s fantasy life must be viewed as a reflection of and determined by the child’s perceptions and interactions within his environment and his unique degree of developmental ma- turity. As an example, a child with specific maturational lags in the motor sphere may succumb to a special type of fantasy elaboration. As maturation progresses, however, the fantasy complex may also change. Similarly, the child with perceptual motor disabilities may exhibit profound anxiety, compensation via wish fulfillment and repetitive fantasy elaboration. If the disability endures, the fantasy theme may become a fixed feature of the child’s character structure. Therefore, in order to understand suicidal behavior in children, it is mandatory to focus upon the complex constituents that eventually combine to create the acting out of suicidal tendencies. These constituent features are the buildmg blocks of each person’s individual psychology. They consist of the child’s involvement in the dynamics of family life, ability to endure external stress and frustration, ability to assess reality, degree of affect display and modulation, and unique capacity for object relations. In addi- tion, in order to understand the role and significance of a suicidal child’s death fantasies, wishes, concepts and behaviors, it is essential to have knowledge pri- marily about the child’s family, external stress factors and level of ego functioning.

The Family Situation of Suicidal Children Several family disruptions such as separation, divorce, death, parental psycho-

pathology and family violence have been associated with the suicidality among children (8, 12, 15, 18, 19). However, many of these features may not be unique to childhood suicidal behavior but rather are contributors to a diverse spectrum of childhood psychopathology. Nevertheless, empirical studies have demonstrated that certain of these factors do have a special role in promoting suicidal behavior of children.

In a study of 60 abused children, 30 neglected children, and 30 normal children, there was a significantly higher incidence of self-destructive behavior such as biting, cutting, burning, hair pulling, head banging and suicide threats and attempts among the abused children (18). It was noted that self-destructive behavior was precipi- tated by parental beatings or in response to a separation from the parent. It was suggested that the parental violence produced in the child a wish to escape from the intolerable interactions of his parents. In addition, the observations of the study revealed that the children seemed to imitate the parent’s aggressive behavior as well as to identify with the parent’s hostility and criticism of himself or herself. As a result, the child regards himself as bad, hostile, destructive, and worthless.

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DEATH PREOCCUPATIONS AND SUICIDAL BEHA VIOR IN CHILDREN 26 5

Such parental repetitive and traumatic violence towards the child depicted in the child abuse syndrome is one severe external stress that may cause in the child severe ego deficits of reality testing, impulse control, and affect regulation. In addition, fixed self images of badness and worthlessness are ingredients to form destructive wishes and fantasies. Fear that these fantasies may be acted out may form the nucleus for intense death preoccupations.

Akin to the rejection and hostility noted for abused children Sabbath (20) postulated the “expendable child” concept. He based his conclusions on clinical observations of suicidal adolescents. However similar dynamics apply to younger children. This concept supposes that “a parental wish, conscious or unconscious, spoken or unspoken that the child interprets their desire to be rid of him, for him to die. The parent perceives the child as a threat to his well being and the child sees the parent as persecutors or oppressors” (p. 273). This idea was expressed by one adolescent girl who said “my parents wanted to make me perfect; they failed, and therefore they want to get rid of me” (p. 274). The girl could not recognize any positive feelings of her parents. For example, she could agree that her mother loved her but said that “it’s because I am her daughter, not because I’m me” (p. 274).

In another case described by Sabbath (20) death wishes toward the adolescent were direct. One mother, when angry at her daughter, told the girl to “drop dead” (p. 279). The mother was unable to tolerate her daughter’s defiance and wanted her to leave the house. As a result, the girl felt that she was the most dispensable member of the family. The suicidal behavior became a compliance of her mother’s desire t o have her out of the house and for her to drop dead.

Dynamics of the expendable child produce a patterned family system in which the child feels intense loss and abandonment. As a result, states of helplessness and worthlessness are produced. These feelings may generate wishes and fantasies of being somewhere else such as in a peaceful state of satisfaction. Death may be considered to provide such a blissful state. Therefore, these fantasies may be a strong element of death seeking desires.

A highly specific family factor for risk of suicidal behavior of latency-age child- ren is parental depression and suicidal behavior. In a study of 58 psychiatrically hospitalized latency-age children, Pfeffer and colleagues (10) documented that there was a significant correlation between parents who were depressed and suicidal and the degree of dangerousness of suicidal behavior of the children. In the entire population of these children, 13 (22 percent) mothers had suicidal ideas, 10 (47 percent) mothers attempted suicide and 2 (3 percent) mothers committed suicide. Among aU the fathers, 2 (3 percent) had thoughts of suicide, 3 ( 5 percent) at- tempted suicide and 1 (2 percent) committed suicide. The findings of this study lead to the hypotheses that the children identify with their parents’ states of helplessness and worthlessness. In addition, the incidence of parental suicidal be- havior provides an actual experience for the child with threats of death. The identi- fication of the child with the parent’s fantasies of death may enhance the child’s suicidal potential. All of these studies share a common trend which points out the great importance

of parental attitudes and emotional states. Parental actions, feelings and affective states influence the child and produce in the child lasting identifications which, in turn, become apparent in the child’s perceptions and fantasies of himself and others. States of helpless despair and worthlessness produce intense psychological

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266 C. R. PFEFFER

pain which must find an immediate release. Suicidal behavior may be one drastic mechanism for the unburdening of intolerable feelings.

Ego Functioning of Suicidal Children

During the long process of development, a child’s mechanisms of adaptation that include the sensory, motor, cognitive and interpersonal functions are changing and becoming fixed characteristics of each person’s unique style of responses. Not only are the biological influences significant but environmental experiences main- tain as much force as the innate and constitutional. The eventual effect can be ob- served in the type of ego functioning that evolves. The paramount components of ego functioning are the degree of reality testing, capacity for affect regulation, intellectual and cognitive functioning, ability t o tolerate frustration, and quality of interpersonal and object relations. Each component of ego functioning can be operationally defined so that it may be evaluated and compared. For example, reality testing is the capacity to respond appropriately to internal and external stimuli and situations. Affect regulation denotes the quality, intensity, and timing of display of such affects as joy, pleasure, anxiety, aggression, sadness, and depres- sion. The intellectual and cognitive functions are a whole set of apparatus that interact to maintain one’s sense of comprehension of circumstances, information storage of experiences, level of academic achievement, intelligence, and integration of perceptual and motor stimuli. The ability to tolerate frustration consists of an individual’s sense of tolerance for frustration, capacity to delay action to a future time, ability to make decisions, and sense of planning for the future. Interpersonal and object relations implies a person’s style of relating to others as well as his inner sense of identity.

Relatively little systematic clarification exists about the quality of ego function- ing of suicidal children. However, there have been several beliefs that are maintained or questions that have been raised. These issues must be rigorously tested to see what degree of validity exists about them. For example, it is said by some that suicidal behavior of children is an impulsive action (7, 21). Others, basing their statements on clinical case evidence, indicate that suicidal behavior although it may superficially appear to have an impulsive quality, is actually not impulsive but rather the culmination of severe long standing family or other enduring external conflicts (22). Unfortunately, by indicating that suicidal behavior in children is impulsive, it has hampered a more systematic approach t o clinical evaluation especially regarding the factors that may have promoted the building up of suicidal tendencies. Therefore, caution is required in concluding that childhood suicidal actions occur precipitiously or in an unexpected fashion.

The issues have been raised as to whether suicidal children are more seriously disturbed than nonsuicidal children. Additional systematic studies using large numbers of suicidal and comparison groups of nonsuicidal children are needed to clarify this issue. A strong proponent of the belief that suicidal children have severe emotional disturbances is Ackerly (5). He studied clinical cases of 31 suicidal latency age children who either threatened or attempted suicide. He believed that a child’s suicidal threats are prompted by complex interactions between a child’s aggressive drives and narcissistic orientation to life. However, children who attempt suicide seem to be in a psychotic state with massive disruptions of adaptive mechanisms and a withdrawal of interest in the world.

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DEATH PREOCCUPATIONS AND SUICIDAL BEHA VIOR IN CHILDREN 26 7

Ackerly (5) therefore, believed that children who threaten and those who attempt suicide represent two distinct groups of children. In contrast, I believe that, at present, there is no proof that children who attempt suicide or threaten suicide should be considered as two distinct groups (1 0, 11). Suicidal behavior is such a complex symptom involving multiple factors that it is premature to dichotomize suicidal behaviors. Instead I prefer to consider suicidal behavior of children as a continuous spectrum of behavior ranging from nonsuicidal, to sui- cidal ideas, suicidal threat, suicidal attempts, and completed suicides. I have docu- mented that there was no difference in diagnoses along the spectrum of seventy of suicidal behavior. Therefore, it cannot be clearly stated that suicidal attemptors are in more of a psychotic state than those children with suicidal ideation or threats. In a similar manner, Mattsson (8) studying suicidal and nonsuicidal child and adolescent emergency cases found n o differences between the primary diag- noses of the two groups of emergency patients.

The role of defense mechanisms in maintaining psychic equilibrium has a central place in the psychoanalytic theories. The defenses are important to modify expres- sion of feelings, fantasy and behavior. They balance and integrate one’s perception of reality, one’s ability to delay impulse discharge, and one’s vulnerability to in- tense affect. It is believed that the capacity for defenses to function is important as the preventative force for expression of self-destructive impulses. However, there are relatively few studies addressing this issue. Pfeffer and colleagues (10, 11) tried to clarify the role of ego defenses for childhood suicidal behavior. Among a sample of 58 suicidal and nonsuicidal psychiatrically hospitalized latency-age children, it was documented that denial, projection, introjection, repression, and displacement were ego defenses commonly noted in this population of children. However, the ego defense profiles were not different for the suicidal and non- suicidal children. This report serves as an example of the type of systematic studies that are still needed to definitively understand the operations of the defense mechanisms in relation t o childhood suicidal behavior.

Another component of ego functioning is the regulation of affect expression. Such regulation includes a variety of affects that are displayed, the timing of when they are evident, and the degree of intensity they are manifest. For example, if a child feels sad and responds to a disappointment, the intensity and timing may range from a transient state of unhappiness that lifts when he realizes that he or she can endure the disappointment to a lengthy display of intense depression because of a feeling of hopeless resignation. Of course, assessment of the child’s capacity for appropriate affect regulation is a key element in understanding suicidal be- havior of children.

Depression has been implicated as the most significant of affects of suicidal behavior of children (8, 10, 11, 23). Unfortunately, there has been great contro- versy about the existence of and the signs and symptoms necessary to diagnose childhood depression. There are some who believe that depression cannot exist in young children because the children have not matured intrapsychially t o be vul- nerable to depression (24). This argument focuses primarily on the component of guilt and superego development. The postulate is that depression is a manifesta- tion of aggression turned inward and directed at internalized bad objects. It is considered that guilt arising from primitive superego functioning is the key mechanism that causes aggression to be turned against the self. This argument, however, is not in keeping with observable phenomena in infants, toddlers or latency-age children. For example, classic studies of Spitz ( 2 5 ) using hospitalized

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26 8 C. R. PFEFFER

infants, pointed out that during the first year of life, infants, when abandoned by their mothers, are vulnerable to anaclitic depressive reactions. Such reactions are observable in infants as not eating or sleeping properly, susceptibility to illness and weight loss, lack of appropriate development and lack of joy, energy or inter- action with others. Among toddlers there have been accurate observations and descriptions of depressive reaction (26, 27). Furthermore, among a study of 100 latency-age children who were treated psychoanalytically at the Hamstead Child Therapy Clinic, London, England, it was discovered that many children showed depressive reaction to a wide range of internal or external precipitating circum- stances (28). The children showed tendencies to regress, disturbances of sleeping and eating, and autoerotic repetitive activities. These children showed sadness, unhappiness and depression. They withdrew and showed little interest in anything. Not only were the children discontented, not easily satisfied, and had little capacity for pleasure, but they communicated a feeling of being rejected, unloved and disappointed. As a result, they were unable to accept help. Sander and Joffe (28) were emphatic in their statement about these children that the depressive reaction in children “can be of a long or short duration, of low or high intensity, and can occur in a wide variety of personality types and clinical conditions” (p. 90).

Although it seems clear to the majority of researchers and clinicians that child- hood depression is an existing entity or syndrome, it is still contended as to what signs and symptoms constitute a diagnosis of depression in children. Some diag- nosticians contend that depression in children may manifest itself in a wide variety of symptoms that can be considered depressive equivalents (29,30). The symptoms are thought to mask the underlying or true depression. Such symptoms include temper tantrums, boredom, restlessness, hypochrondriasis, truancy, disobedience, delinquency, learning disabilities, hyperactivity, aggressive behavior, psychosomatic illness, and self-destructive behavior. Others believe that depression can be con- clusively diagnosed in children by the presence of depressive themes in fantasy, dreams and verbal expression. Such themes include ideas of mistreatment, blame, criticism, loss, abandonment, personal injury and death. Verbal expression of de- pressive ideas also includes a sense of hopelessness, helplessness, guilt, being un- loved, worthlessness and unattractiveness (3 1). In keeping with these controversies, other researchers prefer to diagnose depression in children when explicit signs and symptoms similar to those observed in adult depression exist (32-34). These symptoms include changes in affective, vegetative, and psychomotor functioning, motivation, self regard, and cognition. Required criteria for diagnosing childhood depression, by these standards, would include a duration of a t least 2 weeks of dysphoric mood such as depressed, sad, blue, hopeless, irritable, and at least five of the following signs of change of appetite, and weight, sleeping problems, loss of energy, psychomotor agitation or retardation, loss of interest or pleasure, feelings of self reproach or guilt, decreased ability to concentrate, recurrent ideas of death or suicide.

As can be noted, specific themes and fantasies are associated with depressive reactions. These themes are also central to the elaboration of intense death pre- occupations noted for suicidal children. Furthermore, although many depressed children may exhibit suicidal ideas or behavior, not all depressed children show suicidal symptomatology. Additional clarification is needed io understand the nature of suicidal behavior among depressed children.

Another issue in need of additional study is the relationship of other affects such

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DEATH PREOCCUPATIONS AND SUICIDAL BEHAVIOR IN CHILDREN 269

as aggression and anxiety to suicidal behavior in children. Several investigators have remarked that suicidal children frequently show marked dangerously aggres- sive behaviors towards others (6, 8, 35). Despert (36) studying suicidal children commented that the children he studied showed no evidence of depression but rather definite signs of aggressiveness and impulsive behaviors. However, in view of these observations, it is essential that aggressive tendencies as they relate to suicidal behavior of children be studied systematically.

Death Fantasies and Concepts of Suicidal Children Fantasies are one of the unique aspects of man’s existence. They derive from

the earliest experiences with one’s environment, physiological functions, and sensory perceptual stimuli. The integration of these broad occurrences lead to the specific nature of fantasy. Fantasies usually change as one matures. They acquire more complexity and serve to foster adaptive functioning. In children, fantasy may be obvious in play, verbalization, poetry, art, and music. These avenues for fantasy expression help the child gain mastery over new, frightening, or challenging experiences. They help a child tum passive feelings into activities, help to diminish anxiety, and helplessness by the elaboration of control and mastery through fantasy. In some, fantasy provides for the central characteristics of individual personality formation.

The previous sections of this chapter have pointed out important issues and variables that have been found to be relevant to childhood suicidal behavior. Other significant features are the child’s preoccupations, experiences and concepts of death. This essential component to understanding childhood suicidal behavior derives from the effects of the interactions of the other variables of ego function- ing, developmental phase maturity, and actual and imagined experiences. Unfor- tunately, relatively little has been studied in relation to death concerns in regard to childhood suicidal behavior. This section will briefly highlight the clinical investi- gative work that has important bearing on death issues in childhood suicidal be- havior.

In order to comprehend the suicidal child’s concerns about death, it is essential to understand not only their emotional backgrounds of conscious and unconscious experiences but also the types of age acceptable concerns about death of children in general. Caprio (37) contends that the inevitability of death exerts a profound influence on all human beings and that ideas about death are found in everyone. Furthermore, it is accepted that death attitudes are formed chiefly by experiences in childhood and are often the expression of a child’s conscious and unconscious death ideas directed toward the parent (38,39).

Among children, death is conceived of as a disappearance and is associated with loneliness (40). Anthony (40) noted that in children, death is a sorrowful separa- tion and a “fear bringing thing” that results from aggression. He noted that children associate death with themselves and their experiences with the elderly and observa- tions of animals. The child soon realizes that he or she is getting older and will eventually die. Chadwick (39) emphasized that fear of death in children represents a simultaneous loss of power o r a state of helplessness and also a paradoxically diametrically opposite gain of power or triumph. It must be noted that these seem- ingly contradictory feelings are important influencing factors on suicidal children.

In an attempt to further understand children’s reactions to death, Caprio (37)

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270 C. R. PFEFFER

studied the childhood death memories of 100 adults. It was observed that among the majority of persons death was associated with fear, morbidness and sadness. It was noted that children tended to deny death and believe in their own im- mortality. The memories seemed to indicate that children associate death with punishment, mutilation, and retribution, and that sleep problems may be caused by the identification of sleep with separation and death.

Among one of the earliest empirical studies of children’s theories about death, Nagy (41) attempted to decipher what a child between ages 3 and 10 years thinks death is and what themes they elaborate to explain death. She based her findings on written stories, drawings, and interviews of 378 chddren. She found that child- ren less than 5 years do not comprehend death as an irreversible event. They equate death with sleep or even deny death. Between ages 5 and 9, she discovered that children personified death and think of it as a continuous process with life. That is, death is temporary and can alternate repeatedly with life. The personification of death is apparent as an identification of death with a distinct personality who is invisible and carries people off. Another concept is the identification of death with the dead. After the age of 9, death is conceptualized as an irreversible process that is a universal phenomenon. These developmental schemata are important in relation to suicidal children. Among suicidal children, there tend to be fluctuations in their concepts of death. These fluctuations are influenced by the degree of stress the child is experiencing and the capacity to maintain stability in ego functioning.

One example will illustrate the fluctuations and death concepts and ego func- tioning in a 7-year-old suicidal boy. Allen attempted to kill himself to relieve his confusion resulting from his desperate home atmosphere. His grandfather, who was the most satisfying support for M e n had just died. Previous to the death, Allen understood that death was a final occurrence. In addition, Allen believed that bad people are prone to die more readily than nice people who he believed live to an older age. However, after his grandfather died, Allen repeatedly stated that death is not final and that his grandfather might someday return. In addition, he altered his statements about death and bad people and now talked about death as a pleasant place where good people go. In this child, the developmental pro- cesses were fluid and the child was prone, under stress, to show regression in some of his understanding of death.

Von Hug-Hellmuth (42) gave a detailed acount of a young boy’s evolving con- cepts about death. Death concepts of this child were shown to have arisen from the child’s experiences and served as commentaries of his interactions with the world. For example, the little boy expressed wishes that he could be free from hismother’s prohibitions. He decided this was possible as soon as “she is shot dead” (p. 503). However, later his conscious and unconscious death wishes against his mother became a source of pity and regret. Other illustrations were given of how the child identified the dead with the self and how the child’s death fantasies were connected with the strong sadistic tendencies. The evolution of each individual’s child‘s under- standing of death is strongly influenced by his experiences and availability of supportive adults who can interpret real events. For many suicidal children, ex- periences have been traumatic, violent and lacking in supportive ego strengthening adults who are able to help the child cope with his circumstances and fantasies about death. Instead, such children are often alone to develop their own idiosyn- cratic explanations of what they witnessed and imagined.

An empirical study of 41 school children, ages 3 to 12 years, pointed out that

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while children’s concepts of death generally mature with age, chddren by no means are identical in this process of development (43). It was noted that among those 21 children who expressed realistic concepts of death, 2 were between 4 and 5 years of age, 1 was between 5 and 6 years, and the remainder were older than 6 years. Therefore, in work with suicidal children, it is essential to systematically and inten- sively interview the child in order to understand his specific beliefs about death rather than to make assumptions about these concepts.

In another empirical study, 75 children, ages 6 t o 15 years, were grouped accord- ing to Piaget’s schemata of preoperational level, concrete operational level, and formal operational level. The mean ages of these groups of children were 7.4 years, 10.4 years, and 13.4 years, respectively (44). It was observed that children’s answers to questions about causes of death were related to the child’s level of cog- nitive development. Age alone did not appear to be a sufficient basis upon which to classify or group responses. These findings strengthened the clinical concern for the necessity of thorough clinical evaluation of death concepts when interviewing suicidal children. Koocher (45) emphasized that there should be “no unspoken barriers” in talking with children about death. He noted that “children are capable of talkmg about death and seem to want to do this” (p. 410).

The brief description just offered highlights several facts. First, more empirical data is necessary to understanding children’s beliefs about death, their coping styles when confronted with these issues, and methods of interviewing distressed children. Second, while normative data is slowly accumulating about children’s beliefs about death, relatively little is known about suicidal children’s understanding of this issue. Unfortunately, many assumptions have been fostered which are based on a lack of sufficient data. Third, methods of relieving clinicians’ inhibitions in talking with children about death must be developed. This may be readily accomplished when knowledge and techniques of interviewing about death for children are improved.

Suicidal children, unlike most children, are actively confronting all possible concerns about death. Obviously, their behavior may lead to death or serious injury. However, their motivations for this form of action may vary from child to child. Very little has been defined about the latency-age suicidal child’s concepts about death.

Lourie (46) attempted to explore the nature of death wishes that school children have toward themselves. In speaking with 100 school children with emotional problems, 70 percent reported thoughts and wishes of their own death. Sixty-nine children stated they had consciously wanted to die at one time or other. In a comparison group of 50 normal school children, 54 percent had consciously thought of killing themselves. The chddren stated they hoped to acheve an escape from terrible situations, retaliation toward those who were unjust to the children, and love from others by sacrificing themselves. A few children, 5 percent of the normal children and 12 percent of the disturbed children, admitted using death threats for manipulation.

In comprehensively understanding suicidal behavior of children, it is important to realize that a child’s concepts of death are one ingredient in this type of dan- gerous behavior. Concepts of death include the child’s cognitive and affective orien- tation to death. Concepts of death may include fantasies of what death may be like. It may include repeated thoughts or preoccupations of one’s experiences with death. These issues are somewhat different than the fantasies of the suicidal child

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which includes the goals and aims of what suicidal behavior may accomplish. Such goal related ideas may be called the suicidal fantasies or motivation for suicidal behavior. Considering this clarification, the suicidal child’s cognitive concepts of death will be discussed and then types of suicidal fantasies will be characterized.

Pfeffer and associated (10, ll), attempting to determine high risk variables for childhood suicidal behavior, focused on aspects of latency-age children’s con- cepts of death. Systematic interviews with 58 psychiatrically hospitalized children, ages 6 to 12 years, involved questions focusing on the child’s preoccupations with death that included thoughts of the child’s own death, the death of relatives, dreams about death, and fears about death. The child’s actual experiences with death were examined. These experiences included knowledge of one’s death, at- tendance at a funeral, and involvement with serious physical illness of self or relatives. The child’s cognitive understanding of finality of death was explored. Similarly, the child’s affective orientation toward death was determined. This included estimates of whether the child considered death to be a pleasant, peaceful wished for state or a horrible, frightening, warded off state. It was determined that the suicidal children significantly more frequently were preoccupied with thoughts of their own death than nonsuicidal disturbed children. The suicidal children intensively wished to die. They viewed death as a pleasant state in which problems would be absolved. Furthermore, the suicidal children more often believed that death was reversible. They saw death as a temporary and pleasant solution to their immediate and chronic problems. Suicidal children seemed to have more real experiences with death. They often knew someone who was dying from terminal illness or knew of relatives or family friends who had died. Many of the deaths were by suicide. Almost no latency-age suicidal child knew of the death of an age mate by a suicidal action.

These intense death preoccupations and definite concepts about death have marked relevance for clinical evaluation and intervention with potentially suicidal latency-age children. For example, one 9-year-old boy who I saw in consultation because of his severe behavior problems at school told me during his first interview about worries that his relatives were dying. He was concerned that his mother would be devastated if her sister was sick and would die. The fact was that this aunt did not have a life threatening illness. The child continued to tell me about another aunt who died three years previously. I asked the child what his beliefs were about death. Although he seemed to have a realistic impression that death was final, I was alerted by his intense preoccupations with death. I questioned the child about possible thoughts of wishing he were dead or ideas that he wanted to kill himself. Relieved by my initiating these questions, the boy told me that three months before he considered suicide by threatening to jump out the school win- dow. At that moment in our discussion, the child felt the sense of grief unburden- ing his thoughts that were troubling him.

Other investigators suggested that the suicidal behavior of children may be partly attributed to the child’s view of death (47). An idiosyncratic distorted view of death in children with psychopathology or under severe stress may facilitate suicidal tendencies. Orbach and Glaubman (47) illustrated this in two suicidal girls who considered death as another form of life and a need fulfilling state. These authors hypothesized that suicidal thinking evokes defenses that may result in distortion of the meaning of death. This may eventuate when the emotional pressure endured by the suicidal child may affect his still fluid cognitive structure in the direction of

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DEATH PREOCCUPATIONS AND SUICIDAL BEHA VIOR IN CHILDREN 213

wishful thinking. In their empirical study of interviews about this with 21 school- age children who were divided into 6 suicidal children, 14 aggressive children, and 19 normal children, it was determined that suicidal children attributed cause of death to suicide and considered that there is a life after death (48). However, the aggressive and normal children emphasized the finality of death. In addition, nor- mal children attribute cause of death to natural causes, while aggressive children attribute cause of death to brutality. Orbach and Glaubman (48) concluded that a child’s concepts of death is an integral part of his entire personality and reflects his life experience and internal dynamics. Furthermore, they state that the evi- dence of their study lends support to the notion that the suicidal cud’s distorted death concepts are a reflection of a defensive process. That is, by choosing suicide as a solution to a troubled life, the suicidal child is maintaining that death is another form of life and that he might return to the present life after his death. This protects the suicidal child from actually confronting the realization of death finality. Both Pfeffer and associates (10, 11) and Orbach and Glaubman (48) agree that suicidal children view death as a pleasure and a need fulfilling state, and that these concepts actually facilitate the suicidal behavior. They agree also that at- tempts to promote an aversion of death is one means of fostering a deterrent mechanism to suicidal action in children. Orbach and Glaubman (47) also observed that suicidal children’s distortion of death involves only beliefs about the child’s own death but not so much the child’s belief about other people’s death which in many cases is conceived of realistically. It was therefore concluded that this makes it more likely to propose that the suicidal child’s idiosyncratic ideas of personal death serve a defensive function with denied personal death.

Assuming that these death concepts are one component factor to promoting this suicidal behavior, it may now be possible to integrate these underlying concepts of death with the understanding of the child’s intense motivation toward self- inflicted death. Remembering that suicidal children often view their own death as temporary and a need fulffiing state may help understand various fantasies asso- ciated with suicidal behavior. Therefore, a schema can be conceptualized that inte- grates various types of beliefs and fantasies. The suicidal fantasies are those ideas that propel self-destructive actions. The death concepts are beliefs about personal death and are ingredients of the suicidal fantasies.

The Suicidal Fantasies of Children A common attribute of most suicidal fantasies is that they serve as a communica-

tion. Their origins are based upon the child’s perspective of his real or imagined situation. One function of suicidal fantasies is to be a wish fulfilment. In addition, the suicidal fantasies have a quality of being action oriented and they attempt to transform the child’s perception of his passivity to one of active mastery. Often several suicidal fantasies coexist and are maintained within a single child. However, the timing of their expression may be determined by conscious and unconscious processes. The ultimate aim of the suicidal fantasies is influenced by intense affect, concepts of death, and narrowing or deficits in ego functioning. The ultimate aim is to propel the child toward suicidal action. It must be underscored that the fantasies in and of themselves do not lead to suicidal behavior. These fantasies must be com- bined in the complex fashion with a specific combination of intrapsychic and external variables. To emphasize this concept, Ackerly (5) pointed out that the

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complex forces involved in promoting suicidal behavior include the child’s aggres- sive drives, his narcissistic expectations, his archaic superego, his withdrawal of libido from objects, his alternation of ego by identification, his disappointment at not being able to achieve the aspirations of his ego ideal, his loss of sense of well being or ideal self, his struggle with his early emerging concepts of death, and his attempt to overcome his helplessness by means of wishes or fantasies of reunion with an all giving parent. Furthermore it must be noted that suicidal fantasies, when considered by themselves may be observable in other types of child psycho- pathology.

Bender and Schdder (6) were among the first clinical investigators to describe fantasies for suicidal motivation. They noted that suicidal children are reacting to a perceived deprivation of love by means of aggressive action which punishes the parent. The child views death as an escape from an intolerable situation and a chance to experience a more peaceful state. Unconsciously, such a fantasized peaceful condition stands for the reunion with an idealized nurturing parent. One can see in these dynamics of this type of suicidal fantasy, that death concepts become an integral aspect of the suicidal fantasy. The escape is considered possible only through the act that will inflict death. Such a child rarely sees other alternative means of handling his or her distress.

Ackerly (5) believed that childhood suicidal behavior is based upon a regressive state of ego functioning. Apparent in this ego state is the elaboration of suicidal fantasies which Ackerly called a phoenix motif. This type of suicidal fantasy is the spinning out of the child’s wanting to return to early childhood when he is ideally nurtured by an all giving good mother. Ackerly (5) sees suicidal behavior as a striving to return to the state of primary narcissism or oneness with an idealized mother. Such reunion fantasies are definitively observable in suicidal children who have lost a parent through death and occasionally loss inflicted by separation or divorce. Intense longings to rejoin the lost parent have profound impact on the mourning process as well as to increase the child’s vulnerability of succumbing to psychopathological reactions.

Several other common suicidal fantasies were noted as “a cry for help,” an act of revenge, and a release from inner turmoil in psychic pain (8, 12). A cry for help is the child’s desperate attempt to dramatically highlight his plight of helplessness resulting from overwhelming external stress. Usually this phenomenon is associated with such environmental stresses as family chaos, physical illness and school prob- lems.

The act of revenge or manipulative suicidal fantasy is aimed at teaching a hated parent a drastic lesson. The child uses suicide as a means of gaining what he or she wishes. Often the desire to actually die is minimal. However, this form of suicidal fantasy must be taken with great seriousness especially since the child is fully capa- ble of succeeding at his own actions.

The wish for relief from inner turmoil and psychic pain is often apparent in ex- treme case of confusion, panic or psychosis. The inner suffering is so great that suicidal behavior is an attempt to remove this type of distress. Death is viewed as a peaceful alternative and resolution to this intense inner suffering.

It must be emphasized that these suicidal fantasies are strong motivating factors for suicidal behavior. However, they are important catalysts only when the right combination of ego functioning and stresses are such that they potentiate the possibility for acting out upon wishes and impulses. Therefore, a critical mechanism

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DEATH PREOCCUPATIONS AND SUICIDAL BEHAVIOR IN CHILDREN 215

of acting out upon suicidal tendencies rests with the balance of various ego and defensive mechanisms. The suicidal fantasies will help intensify the potential shift of ego devices toward more ease of acting out that will include suicidal actions.

COGENT PRINCIPLES OF INTERVENTION Much more is to be learned about treatment of suicidal children. As the etio-

logical, natural history, and characteristics of this disorder are explicated, treat- ment directions will become more focused, intensive and potentiating of cure.

The first principle of treatment is establishment of an accurate diagnosis. The diagnosis entails not only an assessment of the quality of suicidal behavior but also the type of constitutional developmental, personality structural, and environmental organization that exists for the child. Therefore, a holistic approach is required for evaluation and subsequent treatment planning.

The establishment of a diagnostic formulation regarding the suicidal behavior requires an interviewing technique of the child that would be facilitating in un- covering of information about the child‘s potential for suicidal ideas, threats, attempts, or completed suicide. Ideas about methods of enactment of this behavior, concepts about death, and ability to be motivated for assistance. Such an assess- ment might be more complex in children than in adults because of children’s reticence and lack of facility with language. Therefore, it is imperative to gather history and observations of the child’s behavior, communication and feeling states from adults who are clearly in contact with the child. Parental and school reports are primary avenues to pursue in data gathering. In addition, interview techniques of children must be tailored to ease communication between the child and the therapist. Methods of interviewing suicidal children should include such modes as talking, playing, and drawing.

It has been noted, for example, that suicidal chddren’s play may have specific themes that may provide clues of potential suicidal action (49). One theme of the potentially suicidal child is of dealing with the developmental issues of separation, loss, and autonomy. T h s may be illustrated in such play as throwing and dropping objects and dolls from heights so that they would be found and rescued. Another manifestation in play of a potential clue to suicidal behavior is repetition of dan- gerous and reckless behavior. This may represent attempts to cope with intense stress by direct motor discharge. A third clue to suicidal behavior is the repetitive misuse and destruction of toys, throwing objects out windows or throwing objects at others. This destructive treatment of play materials may represent a confusion between self and objects in which aggression directed toward the objects actually represents aggression directed towards the self. Another indicator in play of poten- tial suicidal behavior is the repetitive unrealistic acting out of omnipotent fantasies of being superheroes. In this play, the child attempts feats that would actually be dangerous. The need to pretend to be a superhero and to do dangerous things may represent the child’s attempt t o diminish intense feelings of helplessness and vul- nerability.

Once the diagnostic assessment indicates that a child is at serious potential risk, interventions must be immediately planned. The primary concern ought to be in providing the child with immediate constant protection from harm. This may be accomplished by intense observation at home only if it is possible to diffuse suicidal tendencies rapidly by acute outpatient intervention. However, often it is

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too risky to chance this approach and it is questionable if external supports are reliable and effective or if the child is able to form a quick, intense, therapeutic alliance with the distinct motivation to seek alternative means of coping with his or her discomfort. Therefore, acute psychiatric hospitalization may be the choice intervention to ensure protection from harm and then to provide additional diag- nostic assessment and treatment (3 5).

As a means of protecting a child from harm and of unraveling and remedying the family turmoil that may have contributed to the child’s suicidal behavior, it is mandatory to work with the child’s family. It is inconceivable in working with acutely suicidal chlld not to immediately involve the child’s family. All too often this treatment task is overlooked. Morrison and Collier (22) provided further insight into the value of family intervention in crisis treatment of suicidal children and adolescents. These authors noted that suicidal behavior is not only a symptom of individual upheaval but also of long standing family disruption which may be related to forms of threatened or actual separation. They postulated that “if the individual and his family can be seen promptly, the episode can be used in working with them to bring about increased openness of family communication and thera- peutic movement within the system” (p. 141). They advocated a diagnostic inter- view with all family members which should be maintained with regularity as long as acute suicidal symptoms last and until the crisis has been settled. This, of course, can be carried out in conjunction with individual sessions between the therapist and the child. The goal of the family meeting was to identify external situations that provoke the crisis and to clarify the family’s internal susceptibility, develop- ment of symptoms, and means of resolution of these problems.

Another aspect of intervention involves the associated symptoms of the child. These may be related to constitutional, reactive, or characterological concerns. Interventions must be geared specifically to their amelioration. Treatment may include various forms of psychodynamic approaches, medication and academic remediation. No specific one of these forms of intervention is unique to the suicidal child. A note in this regard involves the use of medication which may include any number of types of drug management. For example, a psychostimulant may be indicated for an attention deficit disorder, an antidepressant for severe depression, a major tranquilizer for psychotic behaviors and so forth. Wise and judicious use of medication is most recommended.

Finally, treatment of suicidal children entails a long term approach. Often children must be seen intensely for a period of years. The goal is to channel acting out of suicidal tendencies into verbalization or other symbolic expression. Through this process of treatment, eventual removal of all suicidal impulses can be hoped for. Future follow-up is extremely helpful in providing clues of early warning signs of need for resumption of treatment and also to learn about the long term natural course of this disorder.

REFERENCES 1. Mclntire, M. S . & Angle, C. R . Psychological biopsy in self-poisoning of children and

2. Lowenthal, V. Suicide, the other side.Arch. Gen. Psychiu., 33:838-842,1976. 3. Aleksandrowicz, M. K . The biological strangers: An attempted suicide of a seven and a

adolescents. Amer. J. Dis. of Children, 126:42-46, 1972.

half year old girl. Bulletin of the Menninger Clinic, 38:163-176, 1975.

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DEATH PREOCCUPATIONS AND SUICIDAL BEHAVIOR IN CHILDREN 277

4 .

5 .

6.

7.

8.

9 .

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21. 22.

23.

24. 25.

26. 27.

28.

29.

30.

31,

French, A. P. & Stewart, M. S . Family dynamics, childhood depression, and attempted suicide in a 7-year-old boy. Suicide, 5:29-37,1975. Ackerly, W. C. Latency-age children who threaten or attempt to kill themselves. J. Amer. Acad. Child Psychiat., 6:242-261, 1967. Bender, L. & Schilder, P. Suicidal preoccupations and attempts in children. Amer. J. Orthopsychiat., I :225-233, 19 37. Gould, R. E. Suicide problems in children and adolescents. Amer. J. Psychotherapy, 19:

Mattsson, A., Seese, L. R., & Hawkins, Suicidal behavior in a child psychiatric emer- gency. Arch. Gen. Psychiat., 20: 100-109, 1969. Paulson, M. J., Stone, D., & Sposto, R. Suicide potential and behavior in children ages 4 t o 12. Suicide and Life Threatening Behavior, 8:225-242,1978. Pfeffer, C. R., Conte, H. R., Plutchik, R., & Jerrett, I. Suicidal behavior in latency-age children: An empirical study. J. Amer. Acad. Child Psychiat., 18:679492,1979. Pfeffer, C. R., Conte, H. R., Plutchik, R., & Jerrett, I. Suicidal behavior in latency-age children: An outpatient population. J. Amer. Acad. Child Psychiat., 18:703-710, 1980. Toolan, J. M . Suicide and suicidal attempts in children and adolescents. Amer. J. Psychiat.,

Fredrick, C. J. Current trends in suicidal behavior in the United States. Amer. J. Psycho- therapy, 32:172-200, 1978. Holinger, R. C. Adolescent suicide: An epidemiological study of recent trends. Amer. J. Psychiat., 135:754-756,1978. Shaffer, D. Suicide in childhood and early adolescence. J. Child Psychd. & Psychiat.,

Lukianowicz, N. Attempted suicide in children. Acta Psychiatrica Scandinavica, 44:415- 435,1968. Lomonoco, S . & Pfeffer, C. R. Suicidal and self-destructive behavior in latency-age child- ren. Presented at American Academy of Child Psychiatry Annual Meeting, 1974, San Francisco, California. Green, A. H. Selfdestructive behavior in battered children. Amer. J. Psyciat., 135:579- 582,1978. Shaw, C. R . & Schelkun, R. F. Suicidal behavior in children. Psychiatry, 28:157-168, 1965. Sabbath, J. C. The suicidal adolescent: The expendable child. J. Amer. Acad. Child Psychiat., 8:272-289, 1969. Bakwin, H. Suicide in children and adolescents. J. Pediatrics, 50:749-769, 1957. Morrison, G. C. & Collier, J . G. Family treatment approaches to suicidal children and adolescents. J. Amer. Acad. Child Psychiat., 8:140-153,1969. Toolan, J. M. Suicide in children and adolescents. Amer. J. Psychotherapy, 28:339-344, 1975. Rochlin, G. N . Griefs and Discontents: The Forces of Change. Little Brown, Boston, 1965. Spitz, R. “Hospitalism”: An enquiry into the genesis of psychiatric conditions in early childhood. Psychoanalytic Study of the Child, 1:53-74, 1945. Freud, A. The concept of developmental lines. Psan. St. Ch., 18:245-265, 1963. Mahler, M . Thoughts about development and individuation. Psan. St. Ch., 18:307-324, 1963. Sander, J. & Joffe, W. G. Notes on childhood depression. International J. Psychoanalysis,

Glaser, K. Masked depression in children and adolescents. Amer. J. Psychotherapy, 21:

228-245,1965.

130~719-723,1962.

15 :275-291, 1974.

46:88-96.

565-574,1967. Toolan, J. M. Depression in children and adolescents. Amer. J. Orthopsychiat., 32:404- 415,1967. CyGyn, L. & McKnew, D. Factors influencing the changing clinical expression of the depressive process in children. Amer. J. Psychiat., 131 :879-88< 1974.

Amer. J. Psychiat., 137:445449.

ment. Amer. J. Psychiat., 137:22-25, 1980.

32. Carlson, G. A. & Cantwell, D. P. Unmasking masked depression in children and adolescents.

33. Cytryn, L., McKnew, D. H., & Bunney, Diagnosis of depression in children: A reassess-

Issu

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Ped

iatr

Nur

s D

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278 C. R. PFEFFER

38.

39.

40. 41. 42.

43. 44.

45.

46.

47.

48.

49.

34. Puig Antich, J., Vlau, S., Marx, N. et al. Prepubertal major depression disorder: A pilot

35. Pfeffer, D. R. Psychiatric hospital treatment of suicidal children. Suicide and Life Threat-

36. Despert, L. J. Suicide and depression in children.Nervous Child, 9:378-389, 1952. 37. Caprio, F. S. A study of some psychological reactions during prepubescence to the idea of

death. Psychiatric Quarterly, 24:495-505, 1950. Bromberg, W. & Schilder, P. The attitudes of psychoneurotics toward death. Psycho- analytic Review, 23:l-25.1936.

study. J. Amer. Acad. Child Psychiat,, 17:695-707,1978.

ening Behavior, 8 : 1 50-1 60,197 8.

Chadwick, M. Notes upon the fear of death. International Journal of Psychoanalysis, 10:

Anthony, S. The Child’s Discovery of Death. Harcourt-Brace, New York, 1940. Nagy, M. The child’s theories concerning death. J. Genetic Psychology, 73:3-27, 1948. Von Hug-Hellmuth, H. The child’s concept of death. Psychoanalytic Quarterly, 34:499- 516,1965. Melear, A. Children’s conception of death. J. Genetic Psychology, 123:359-360, 1973.

321-334,1929.

Koocher, G. P. Childhood,- death and cognitive development.-Developmental Psychology, 8~369-375.1973. Koocher, G. P. Talking with children about death. Amer. J. Orthopsychiat., 44:404-411, 1974. Lourie, R. S . Clinical studies of attempted suicide in childhood. Clinical Proceedings Children’s Hospital of D.C., 22:166-170, 1966. Orbach, I. & Glaubman, H. The concept of death and suicidal behavior in young children: Three case studies. J. Amer. Acad. ChildPsychiat., 18:668478,1979. Orbach, I. & Glaubman, H. Suicidal, aggression, and normal children’s perception of personal and impersonal death. J. Clinical Psychology, 34350-857,1978. Pfeffer, C. R. Clinical observations of play of hospitalized suicidal children. Suicide and Life Threatening Behavior, 9:235-244,1979.

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